Provider Demographics
NPI:1952151763
Name:WALL, KENNEDY RYANN (T-LMHC)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:RYANN
Last Name:WALL
Suffix:
Gender:F
Credentials:T-LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 PARK AVE APT 2-26
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-3410
Mailing Address - Country:US
Mailing Address - Phone:402-214-5595
Mailing Address - Fax:
Practice Address - Street 1:600 5TH ST STE 300
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-6072
Practice Address - Country:US
Practice Address - Phone:515-233-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA124165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health